PERSPECTIVE

Michelle E. Anderson,* Sarah Emoto,* Sofia Gruskin, and Laura Ferguson

Introduction

In every country, population health is governed not only by health interventions but by a complicated array of laws and policies developed over decades, often emanating from different parts of government. While the true impact of legal and policy frameworks depends on how they are implemented, supportive legal and policy frameworks are known to be essential for creating an environment that supports the realization of health-related rights.

For decades, participatory dialogue processes have been recognized as useful to support agenda setting, priority setting, and action across a range of health topics.[1] As global public health faces increasing constraint and contestation—including stretched resources, intensifying political polarization, and ideological dispute over health law- and policymaking—dialogue processes can play an important role in navigating disagreement and building shared understanding and ownership of legal and policy reform and implementation. While dialogue has been widely implemented as a mechanism for change, comparatively little consolidated guidance exists on how to design, implement, and follow up on multi-stakeholder legal and policy dialogues, particularly in politicized and legally complex environments. Much of the dialogue work that has been done remains institutionally embedded, context specific, or undocumented in ways that hamper cross-learning.

Here, we focus primarily on national-level multi-stakeholder legal and policy dialogues, which function as structured fora in which diverse actors identify actionable pathways for using law and policy to better support public health. In this context, poor or inequitable health outcomes can provide an entry point for examining the legal and policy environment. For example, in cases where health outcomes remain poor despite existing programs or commitments, reviewing laws and policies can help clarify what exists on paper, gaps in protections or guidance, and where implementation gaps or breakdowns may be contributing to the problem. Even where a specific service is legally available, there may be legal restrictions regarding who can access it, contradictory laws and plural legal systems may leave clients and providers confused about what their respective entitlements and liabilities are, or supportive laws and policies may not be consistently implemented or funded.[2]

The utility of multi-stakeholder dialogues exists in part because different stakeholders bring distinct forms of knowledge and experience and may have incomplete or contested information. Bringing these perspectives together in structured dialogue can help generate shared understanding, clarify institutional responsibilities, and build the legitimacy and ownership necessary to advance legal and policy reform. In these settings, government actors can draw attention to relevant laws and policies across sectors, as well as to strengths and challenges in implementation and within existing systems; communities can provide insight into barriers experienced on the ground; and technical experts may introduce evidence that reframes entrenched debates. While examples exist of legal reform following multi-stakeholder dialogues, equally important are the long-term collaborations that can arise across different types of stakeholders.[3]

To better understand how dialogue processes are conceptualized and implemented in contested health domains, we first sought to examine guidance on multi-stakeholder dialogues related to sexual and reproductive health and rights (SRHR), a field in which many of the governance challenges now emerging broadly across public health have long been visible. Despite the long history of policy dialogues, we identified relatively little SRHR-specific dialogue guidance integrating legal analysis, policy processes, and the particular challenges of addressing contested SRHR issues and contexts.

Second, seeking to respond to these gaps and maximize learning around how dialogue processes can best be designed and implemented, we drew on broader health-related dialogue literature to identify adaptable approaches and practices. We also drew on global rights-based frameworks and tools relevant to SRHR, recognizing that while these were not developed explicitly as dialogue guidance, they offer principles, benchmarks, and design considerations that can inform SRHR dialogues.[4] Despite their fragmented nature, these sources offer insights into how dialogues have been designed, implemented, and taken forward, with attention to practical considerations, normative principles, and their ultimate utility in different contexts.

Integrating law and policy in dialogue processes

This commentary is grounded in the recognition that law and policy are interdependent and inextricable in practice and that engaging with both is critical to effective dialogue. Legal frameworks shape what policy options are permissible and who holds authority, while efforts to implement policy commitments often reveal where existing laws are unclear, internally inconsistent, or misaligned with policy goals. Dialogue processes that do not explicitly address these dimensions risk producing outcomes that are institutionally unrealistic or not legally viable.

Sexual and reproductive health and rights as an instructive lens

In the domain of SRHR, the interdependence of law and policy is especially visible; legal and regulatory frameworks directly shape access to and the use of services, the allocation of authority, health outcomes, and the realization of rights. SRHR offers an instructive lens not because it is uniquely politicized but because it has long operated within ethical, political, and rights-based terrain marked by contested norms and uneven protections that are increasingly characteristic of debates across public health. In such contexts, dialogue is not a purely technical exercise; it plays a key role in addressing the institutional and normative dimensions that shape both its process and outcomes. Lessons from SRHR-related efforts can therefore help clarify and signal ways of addressing dialogue design and facilitation challenges that may also arise in other contested areas of health.

First, at a conceptual level, disputes among stakeholders around SRHR-related topics may be grounded in foundational disagreements about autonomy, morality, constructions of gender, or the scope of rights protections for different populations. For example, abortion and comprehensive sexuality education are both issues where technical evidence alone may be insufficient to address particular legal, political, and cultural contexts.[5] In such settings, dialogue cannot assume a shared problem definition or a neutral evidentiary baseline. Consensus may be difficult, fragile, or inappropriate as an endpoint. Dialogue design therefore requires intentional framing, explicit engagement with normative principles, and clarity about realistic forms of agreement. In these contexts, dialogue may function less as a mechanism for resolving disagreement and more as a structured process for clarifying points of divergence, identifying institutional constraints, delineating how services can best be delivered given those constraints, and where progress remains possible.

Second, power dynamics frequently shape who can meaningfully and safely participate in dialogues, and whose inputs are allowed to carry the most weight.[6] While power dynamics are present in any dialogue process, some communities may face social sanction, criminalization, or reputational harm in ways that hinder their ability to engage. For example, a national dialogue in the Democratic Republic of the Congo provided an opportunity for representatives of the community of men who have sex with men to engage with a range of duty bearers, but there was limited participation by transgender populations, perhaps reflecting their relative lack of organization compared to other criminalized populations.[7] Participation is not neutral, and inclusion alone does not guarantee meaningful engagement. Dialogue design must attend to safety, facilitation strategies, sequencing, representation, and risk mitigation in ways that recognize and address power asymmetries.

Third, SRHR issues may shed light on legal pluralism, restrictions, or uneven rights protections. National laws may conflict with policy commitments, constitutional provisions, customary systems, or international obligations. For example, an analysis of SRHR-related laws across 153 countries found that 36 reported at least one instance in which a plural legal system could impede effective implementation of an existing legal guarantee, with contradictions most frequently impacting access to contraceptive services and emergency contraception.[8]

Finally, efforts to understand the root causes of poor or inequitable health outcomes often expose misalignment between evidence, policy goals, and law. Evidence may support certain interventions that are nonetheless restricted by the legal environment; policy commitments may outpace statutory reform; or implementation may be constrained despite formal legal protections. In such settings, dialogue is not merely a mechanism for evidence exchange but a site where legal, technical, and normative claims intersect and sometimes clash. Reform space may be limited by political dynamics or judicial interpretation, even where dialogue seeks to assess or advance legal change. Dialogue processes must therefore explicitly account for the sociopolitical terrain in which health issues are addressed, including how legal and policy barriers may shape the feasibility of reform. Integrating legal analysis and political scoping alongside technical evidence, whether the objective is implementation, interpretation, or reform, can help improve alignment and health outcomes even across different political contexts.

Existing dialogue guidance: Lessons and gaps

The dynamics noted above highlight why it is critical to understand how dialogue processes are currently conceptualized, designed, and implemented, and where existing guidance falls short.

Models of dialogue

Across academic and gray literature on dialogue processes, there is no singular dialogue model, and dialogue definitions and conceptualizations vary considerably.[9] Within this broader landscape, policy dialogues and legal dialogues represent two commonly referenced approaches.

Policy dialogues are commonly framed as iterative and participatory knowledge translation processes for supporting evidence-informed policymaking. Such dialogues typically emphasize clearly defined objectives, transparency, skilled facilitation, and interaction among a broad range of actors, including those who influence, implement, or are affected by policy.[10] Depending on context, they may aim to produce tangible outputs such as decisions, plans, or formal recommendations, and they are often linked to broader governance structures.

Legal dialogues, sometimes called “national dialogues,” tend to convene actors who draft, interpret, enforce, or are governed by law, including legislators, government officials, judicial representatives, civil society advocates, and affected communities.[11] The scope of legal dialogues can range from broad legal assessments to targeted consideration of specific statutory or regulatory provisions.[12] Like policy dialogues, legal dialogues may be embedded within broader governance processes and shaped by political context, particularly where health issues are contested.

Although policy and legal dialogues are both recognized approaches, and both tend to convene similar stakeholders, they are often conducted separately. Policy dialogues may proceed with insufficient attention to statutory or constitutional constraints, while legal dialogues may focus on formal provisions without grappling sufficiently with implementation, financing, or administrative or lived realities.

Common practices and helpful lessons

Although definitions and formats vary, the literature points to several common practices and lessons for typical dialogue process design and conduct. Dialogue is commonly framed as an iterative process requiring sustained engagement throughout legal and policy cycles, rather than as a one-off event.[13] Sources consistently emphasize ensuring meaningful participation from a broad and inclusive group of participants who reflect the range of perspectives, interests, and diversity in expertise and lived experiences necessary to support legitimate and sustainable reform. Emphasis is consistently placed on engaging affected communities, especially marginalized groups and those historically excluded from policymaking processes, with some guidance recommending pre-meetings, orientation, or targeted capacity-building to enable meaningful participation by those with less experience in policy processes.[14]

Operationally, early preparation, stakeholder mapping, facilitation strategies, and accountability mechanisms are regularly identified as critical to effective dialogue.[15] Sources on SRHR-focused policy dialogues emphasize strategic framing, including situating contested topics within broader entry points perceived to be less controversial.[16] While general dialogue guidance does not always explicitly reference rights, many recommended practices align with the principles of participation, equality and nondiscrimination, transparency, and accountability. Additionally, rights-based tools and frameworks developed in other areas may offer complementary framing strategies, benchmarks, and assessment approaches that can inform rights-based dialogue design, even if not originally developed for that purpose. For example, a toolkit on advancing rights-based universal sexual and reproductive health includes a series of questions and indicators as benchmarks across key topic areas (e.g., maternal health and gender-based violence), which may be useful in shaping a dialogue process to assess legal and policy gaps.[17]

Gaps in operational guidance

While existing literature points to several agreed-upon lessons about dialogue practice, it also leaves many practical questions unanswered. In particular, operational guidance is often uneven across stages of the dialogue process, from preparation to conducting the dialogue to follow-up.

Preparation is arguably the most critical phase for ensuring dialogue success, yet it remains among the least documented. Many available resources focus on facilitation or immediate outputs, with comparatively less attention to issue scoping, political mapping, or the strategic framing needed to enter into the dialogue process. Guidance rarely details how to align dialogue objectives with existing data, ongoing reforms, or institutional mandates, or how to clarify the respective roles and responsibilities of those affected by or responsible for addressing the problem. As a result, early-stage planning, particularly in politically sensitive contexts, may be under-resourced or under-specified. Without deliberate political and legal scoping—including identifying which institutions and levels of government hold relevant authority, which actors are likely to support or resist change, and which external developments (such as elections or funding changes) may affect reform—dialogues risk convening actors with insufficient clarity on decision-making authority, reform feasibility, or the institutional levers available for change, leading to recommendations that lack ownership or realistic implementation pathways.[18]

Facilitation guidance often includes practices such as using smaller working groups to encourage participation by underrepresented stakeholders and deliberately creating space for lived experience in the dialogue process.[19] However, there is limited direction on how to navigate deep normative disagreement, legal uncertainty, or power asymmetries among participants, which may be of particular concern in environments characterized by restrictive laws, contested norms, stigma, or institutional fragmentation. Many resources appear to implicitly assume that legal and political contexts are relatively stable and that health policymaking can be treated primarily as a technical endeavor.

Sustained follow-up is frequently identified as essential for long-term impact yet rarely described in detail. Monitoring and reporting mechanisms, where referenced, are often framed broadly and may not extend long enough to ensure the achievement of agreed outcomes. While policy-specific dialogues are most likely to be embedded within existing governance structures, even here guidance provides little detail on operationalizing longer-term accountability.

These gaps point to a fragmented methodological landscape. Much of the dialogue guidance is too general, while the SRHR-related and rights-based tools that do exist are not designed for dialogue processes. As a result, those seeking to conduct SRHR-focused legal and policy dialogues—or dialogues in other contested health domains—must rely on an inadequate patchwork of resources.

Conclusion

Across multiple areas of health—including vaccination, pandemic response, and harm reduction—interventions are increasingly being determined not just by evidence but by contested values, legal constraints, and shifting politics. In this regard, dynamics long visible in the SRHR field offer an instructive vantage point for thinking about how best to address contested health issues.

Dialogue can provide a structured forum to navigate complexity and disagreement, build shared understanding and institutional ownership needed to advance reform, and ultimately improve health outcomes. However, the likelihood that such dialogue will be useful depends on the ways its design takes into account institutional, normative, and political realities. Dialogue must grapple explicitly with these realities, as well as the power asymmetries and limits imposed by existing legal frameworks and their implementation.

We are calling for the development of methodological guidance that integrates legal analysis, political scoping, and rights-based considerations across all stages of SRHR-specific dialogue design and implementation. While no single model can be universally applicable, methodological guidance has been shown to be valuable for consolidating lessons from past efforts and translating them into more systematic and adaptable approaches.

As pressures on public health governance intensify, strengthening dialogue practice in contested health contexts will require systematic attention and continued refinement. Greater operational clarity is needed on how to scope reform realistically, ensure that marginalized voices have a true place at the table, navigate deep disagreement without defaulting to superficial consensus, and align dialogue outcomes with enforceable legal and policy mechanisms that support accountability and the realization of health-related rights. Documenting and refining dialogue practice across contexts will be essential not only for SRHR but for strengthening governance across public health domains, thereby helping ensure that health-related legal and policy dialogues fulfill their purpose and effect positive change in public health governance, interventions, and outcomes.

Funding statement

This project was funded with generous support from the United Nations Population Fund.

Use of artificial intelligence

No AI tools were used in this manuscript.

* Anderson and Emoto are joint first authors.

Michelle E. Anderson, PhD, MPhil, was a research program specialist with the Institute on Inequalities in Global Health, University of Southern California, Los Angeles, United States, where this work was conducted, and is currently the program director of the Future of Peace at World Peace Foundation, Tufts University, Somerville, United States.

Sarah Emoto, MPH, is a research program specialist with the Institute on Inequalities in Global Health, University of Southern California, Los Angeles, United States.

Sofia Gruskin, JD, MIA, is the director of the Institute on Inequalities in Global Health and distinguished professor of population and public health sciences and law at the University of Southern California, Los Angeles, United States.

Laura Ferguson, PhD, SM, MA, is the director of research at the Institute on Inequalities in Global Health and associate professor of population and public health sciences at the University of Southern California, Los Angeles, United States.

Please address correspondence toLaura Ferguson. Email: Laura.ferguson@med.usc.edu.

Competing interests:None declared.

Copyright © 2026 Anderson, Emoto, Gruskin, and Ferguson. This is an open access article distributed under the terms of the Creative Commons Attribution-Noncommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

References

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[3] L. Ferguson, A. Nicholson, I. Henry, et al., “Assessing Changes in HIV-Related Legal and Policy Environments: Lessons Learned from a Multi-Country Evaluation,” PLOS One (2018).

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[6] Cottingham et al. (see note 4).

[7] Ferguson et al. (2018, see note 3).

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[11]. United Nations Development Programme, National Dialogues on HIV and the Law: A Practical Manual for UNDP Regional HIV Teams and Country Offices (2014).

[12]. Ibid.

[13]. Boyko et al. (see note 1); Mitchell et al. (see note 1).

[14]. The Sure Collaboration, Sure Guides for Preparing and Using Evidence-Based Policy Briefs: 8. Informing and Engaging Stakeholders (2011); Health Policy Project, Capacity Development Resource Guide: Policy Dialogue (Futures Group, Health Policy Project, 2014); UNFPA (2019, see note 4); E. Robert, D. Rajan, K. Koch, et al., “Policy Dialogue as a Collaborative Tool for Multistakeholder Health Governance: A Scoping Study,” BMJ Global Health 4/Suppl 7 (2020); Ministry of Foreign Affairs (see note 5); UNFPA, My Body, My Life, My World Operational Guidance. Module 9: Advocacy and Policy Dialogue (2022).

[15]. Partnership for Maternal Newborn and Child Health and World Health Organization (see note 10); World Health Organization Regional Office for Europe (see note 10); United Nations Development Programme (see note 11); O. Biermann, T. Kuchenmüller, U. Panisset, et al., “Policy Dialogues: Facilitators’ Perceived Role and Influence,” International Journal of Health Governance 23/2 (2018); U. R. Loi, A. Coates, O. Obubah, et al., “Expanding Access to Sexual and Reproductive Health and Rights Through Evidence-Based Policy Dialogue: Implications for Practice from a Multicountry Initiative,” BMJ Global Health 8/Suppl 4 (2025).

[16]. Ministry of Foreign Affairs (see note 5); Loi et al. (see note 15).

[17]. UNFPA and Center for Reproductive Rights (see note 4).

[18]. E. Alvarez and J. Lavis, Implementing Health Systems Guidance: A Workbook to Support the Contextualization of Recommendations at the National or Subnational Level (McMaster Health Forum, 2016).

[19]. Boyko et al. (see note 1); Robert et al. (see note 14); UNFPA and Center for Reproductive Rights (see note 4).